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Medicare Interest

Medicare Interest Questionnaire

This questionnaire should take about 5 minutes to complete.

Step 1 of 9

11%

This field is for validation purposes and should be left unchanged.

What is your current Medicare status?(Required)

I'm currently on Original Medicare (Parts A & B)

I'm on a Medicare Advantage (Part C) plan

I'm turning 65 within the next 3 months

I'm not on Medicare yet, but I want to learn more

I'm helping a parent or loved one with Medicare

Are you currently enrolled in a Medicare Supplement (Medigap) or Advantage plan?(Required)

Yes – Supplement (Medigap)

Yes – Advantage (Part C)

No – I'm exploring my options

Not sure

What is your primary reason for considering a new Medicare plan?(Required)

I want to lower my monthly premiums

I want better coverage or provider options

I’m turning 65 and need to sign up

I’m not happy with my current plan

What is your ZIP Code?(Required)

ZIP Code

Are you ready to speak with a licensed agent in the next 24–48 hours?(Required)

Yes

I need a few days

Just browsing for now

What is your preferred method of contact?(Required)

Phone Call

Text Message

What is your best contact number?(Required)

Name(Required)

First Last

Email Address(Required)